Diversity in GI ‘actually matters and actually saves lives’

While 2020 brought diversity to the forefront of many physicians’ minds, 2021 brought about more concrete action.

Healio Gastroenterology had the opportunity to listen to GI leaders engaging in concrete change – from the launch of new associations to the mentorship of the next generation of gastroenterologists – about what diversity means in three distinct areas and how representation impacts patient care.

“To me, diversity means that a profession accurately reflects the population it’s serving. It’s that simple,” Ugo Iroku, MD, MHS, secretary and co-founder of The Association of Black Gastroenterologists and Hepatologists (ABGH), New York Gastroenterology Associates, said. “Every region, state, city and municipality deserves to be served by a body, in this case of gastroenterologists, that is fully versed in its needs, values, viewpoints and challenges.”

“The patients who we serve are extremely diverse, and especially in GI, we tend to see patients at their most vulnerable,” Malorie Simons, MD, an advanced endoscopy fellow at Weill Cornell, said. “It’s important for them to know that, as physicians, we’re vulnerable too, and we can have that connection. And so, if a patient feels more comfortable speaking to a physician knowing that, ‘Hey, that doctor is like me,’ that’s incredibly powerful for the patient-provider relationship.”

“Diversity in GI means not only inclusivity, but also the celebration of our differences in race, culture, sexual orientation, gender, religion and more within our field and among our patients. It also means paying more attention to greater representation and equity in our workforce,” Austin Chiang, MD, MPH, a Thomas Jefferson University endoscopist nominated for the GLAAD’s TikTok Queer Advocate of the Year, said.

“It’s incredibly important to have discussions around diversity and inclusion at the forefront to encourage everyone in the medical field, including GI, to begin thinking about diversity, to understand that diversity spans several areas, and how we as a professional society can work toward creating a more diverse and inclusive health care workforce,” Lukejohn Day, MD, professor of medicine at UCSF and the Chief Medical Officer at the Zuckerberg San Francisco General Hospital, said. “In medicine, we always want to improve. We always want to enhance the care that we deliver. We should do the same thing as it relates to diversity in our field.”

“Diversity in GI means having a practice where providers are from multiple backgrounds, cultures and experiences,” Sunanda V. Kane, MD, from Mayo Clinic told Healio Gastroenterology. “A team rich in diversity brings different viewpoints to the table, which only enhances the care we can provide to our patients.”

“Diversity, equity and inclusion are integral aspects of our academic and clinical work, and critical to providing the best possible patient care,” Allison Schulman, MD, associate professor of medicine and surgery, University of Michigan, told Healio Gastroenterology. “I’m glad these issues are gaining increased attention from leadership of medical institutions and beyond.”

Kane said more patients are recognizing that having access to health care providers of different backgrounds enhances their journey of care.

Increasing Representation of Women

Kane said “representation from all races, ethnicities and cultures serves as a beacon for others who may not have considered a career in gastroenterology before this. It is important to have role models and examples of successful practitioners from all walks of life.”

Kane has a leadership role in the field of GI, previously serving as the president of the American College of Gastroenterology.

“It is an honor and privilege to be looked upon as a leader in gastroenterology,” Kane said. “With that honor comes responsibility to mentor, advocate, champion and support my female colleagues, peers and trainees.”

Schulman, director of bariatric endoscopy at the University of Michigan, said it is powerful for trainees to see faculty members and role models who share similar backgrounds to them. She said many find it difficult to see themselves entering a field dominated by individuals who all look the same and have little in common with those aspiring to join the field.

“It’s important to have diversity within any division, within any subspecialty, within any research endeavor, because we know patient outcomes are better when team members approach things in different ways. It takes effort to change the system, and there is much more work to do without our own field of interventional endoscopy,” Schulman said.

Kane noted women are underrepresented in GI, but she said fortunately that is changing.

“Women have historically not gone into procedure-heavy disciplines because of the on-call aspect of the practice. This is changing as the role of caregiver has changed and more men are staying home to care for children,” Kane said.

Kane said work-life balance is a huge focus in women in GI talks at conferences because historically women cared for the family and household and not just their careers.

“Trying to build a career and run a family/household is impossible to do without something ‘giving’ or else a lot of help,” Kane said.

Schulman said when she first began her training there were very few women in interventional endoscopy. While the numbers have improved, she said there is a lot more work to do as a field. In 2019, only 12.8% of applicants who matched in advanced endoscopy fellowship programs were women. Schulman said there is more interest in the field especially now that women have a voice through various outlets such has social media and with increasing virtual opportunities.

Schulman and colleagues published a paper in Endoscopy International Open highlighting barriers for women seeking a career in advanced endoscopy. These authors confirmed the importance of having women in leadership roles in endoscopy, as advanced endoscopy fellowship programs with more female faculty and endoscopy chiefs were more likely to have female advanced endoscopy fellows. Additionally, program directors ranked increasing the number of female mentors and increasing the visibility of women advanced endoscopists at national conferences as two of the top facilitators to improving gender balance within this subspecialty.

“We’re trying to bring to light a lot of these issues, and on a national level, I’ve noticed at least over the past couple of years that people are no longer interested in just seeing men on the podium. They want to see diverse representation,” Schulman said.

Schulman said some patients have implicit bias regarding the sex of a physician. As a female advanced endoscopist, she feels she has to prove herself.

“On the flip side, there are women who prefer female endoscopists,” Schulman said. “While a subset of patients may seek out specific providers, there continues to be a lot of bias built into the system. It is not uncommon for my male colleagues to be called doctor and for me to be called hon, or ma’am, or miss. Or for me to walk into the room, and for a patient to say, ‘But where’s my endoscopist?’”

Kane said some studies demonstrated patients prefer female endoscopists or health care providers and will wait longer or pay more to see a female physician.

“We are viewed differently and there are data to prove that,” Kane said. “We are perceived as gentler at endoscopy with patients willing to wait longer and pay more for a colonoscopy done by a woman.”

Regarding patients, Kane said input from all viewpoints allows for all perspectives of patients to be considered when making treatment decisions. She said it is vital for physicians to understand different backgrounds or cultural nuances because that can make or break a therapeutic relationship. This could mean a difference between a patient who may become well or one who will continue to suffer.

Though Schulman sometimes feels the pressure of being a woman in a male-dominated field, she said University of Michigan is very supportive, with strong female role models, including in advanced endoscopy.

“I feel very comfortable in my work environment but certainly every day I’m reminded that I’m a woman in interventional endoscopy,” Schulman said.

The ‘Glass Ceiling’ of Race

According to 2019 data, despite representing 13% of the general population, Black physicians are few in the field of gastroenterology and hepatology (>4%) and accounted for less than 7% of the medical student population and 5% of the practicing physician population.

Translated, these numbers carry significant implications on racial concordance between physicians and vulnerable populations. Further, while diversity in GI is morally appealing, it also leads to more effective medical care as studies have shown Black physicians are more likely to care for underserved Black communities.

Like certain women seeking women providers, Black males are more likely to undergo more invasive tests, like colonoscopies, if advised by a Black physician. On a broader scale, this phenomenon is seen in terms of a patient’s need and desire to be adequately heard and understood in a setting where they feel comfortable and valued.

Iroku said representation is a key first step to mitigating many of the racial disparities in medicine today.

“There is a glass ceiling that exists for minorities of different sorts, whether it’s minorities of race, gender or even religion. Sometimes, in certain fields, seeing that glass crack does something to encourage the next generation to know that they can do it as well,” Iroku said. “In the same way that seeing Barack Obama normalized the expectation of diversity in the White House for young public servants, or that seeing Leonidas Berry, MD, the first Black gastroenterologist, normalized that Black medical students and trainees could indeed get into the field.”

While the need to mitigate Black health disparities within both the workforce and the community has been longstanding, 2020 and the deluge of recorded examples of systemic racism, reaffirmed the need for advancement in overcoming the larger barrier of racism in medicine. To this end, a group of professionals committed to positive change in digestive health equity established ABGH.

“The heart of ABGH lives in the Black community. What we have achieved thus far and what we look to accomplish moving forward with this growing group of future and current Black gastroenterology, hepatology and digestive disease scientist ABGH members is for Black people to truly live their best life,” Sophie Balzora, MD, FACG, ABGH president and co-founder, NYU Grossman School of Medicine, said. “The essence of health equity is exactly this, because health touches every aspect of our lives in small and big ways. ABGH as an organization works to channel its members’ and allies’ energy and momentum toward the goal of health equity through workforce diversity, equity and inclusion, through community engagement and by improving digestive health outcomes for Black people.”

An additional barrier at play is how the social determinants of health exposes certain races to specific conditions. Physicians must question whether poor health is reflective of a person’s genetics or a byproduct of environment or limited access to health care (eg, Black households are more likely to live in poverty and were unable to work from home during the COVID-19 pandemic).

“All these social determinants of health tumble and collect together and actually form negative outcomes,” Iroku said. “Being aware of the social dynamics at play, above and beyond the clinical issue at hand, helps me to cater a broad and empathetic treatment plan that makes sure that no man is left behind.”

The ideal future of GI is one where the profession can accurately reflect the population it’s serving; it’s also one where you are always asking what you, as one individual, can do to shift the course of equality in health care. For Iroku, there are three major points on the personal route to answering this question: having humility in understanding that we do not often understand the varied contexts a patient is operating in; having curiosity in learning what is going on locally outside your office in the community you serve; and empathy in comprehending the real and significant factors at play challenging your patients’ treatment course.

“When you look at the bigger picture and understand what diversity brings to the table, you start to understand that some of the effectiveness and the intelligence of our field comes from being diverse,” he concluded. “America is special for a reason. One of our strengths is our diversity; we are a nation of immigrants built around the concept that we are a diverse group and we’re better for it.”

Invisible Diversity

Though women and physicians of color are obvious both to their colleagues and patients, diversity is not always discernable.

“For most people, race or ethnicity is something that you can’t hide from your patients. But you can hide who you’re married to or who you love, if you choose,” Simons said.

“Diversity doesn’t always refer to characteristics that are visible. We must therefore lend greater visibility to the matter to dismantle any systemic bias that could be affecting our colleagues and our patients,” Chiang said.

Simons suggested this comes at an institution level, showing a united front for practitioners and patients alike while allowing those within the LGBTQIA+ community to choose their comfort in sharing their personal lives.

“What would be helpful is if the major academic organizations – and many are doing just this – release public statements saying that not only should diversity be celebrated but any action toward the contrary is unacceptable and will not be tolerated,” Simons said. “That shows the support for not only your staff and colleagues but also patients. ... That is very important and should happen at the hospital level as well.”

As a provider who identifies as a member of the LGBTQIA+ community, Simons said the lines are blurred as to how ‘out’ people feel they should be or have to be to advocate for their community.

“Do we have a responsibility to advocate? Do we have a responsibility to out ourselves? For me personally, I have never mentioned to a patient that I have a wife. I say that I have a spouse and I have a child. But I am lucky in that way that I don’t have to. Whereas some people, wherever their diversity lies, may not have that opportunity,” she said. “First and foremost, I’m a physician, I’m a woman, I’m a spouse, I’m a mother. I know for a lot of people in the LGBTQ+ community, that is how we want to be known. ... So I admit, I am still learning how to navigate this – specifically, how open we should be, to whom and when. I am not sure there is a right answer.”

Day, who identifies as a gay man as well as an American Indian, discussed how representation in a practice or on a medical campus can create a safe space for patients and health care workers alike.

“You want to create a welcoming environment for patients where they feel that everyone is welcome, that everyone is respected, that everyone is represented,” he said, saying it is something consciously shown at his hospital. “It really is trying to create a safe space so patients know when they come there, they can feel free to be who they are and feel free to express themselves and not feel any sense of fear that they’ll be judged.”

This extends into the person-to-person interactions, with HCPs asking for pronouns, preferred name, etc. at the very beginning of an appointment.

“We capture all of this information upfront, and we have very clear ways of making sure that this information gets communicated to our staff because we want to ensure that everyone is respected and feels welcomed at our hospital,” Day said.

While these interventions should be employed across all of medicine, Day said GI has an extra layer of sensitivity with procedures such as endoscopy.

“As a gastroenterologist, it behooves us to establish and strengthen that patient-provider relationship, making sure that we’re meeting the patient where they’re at, asking what concerns they have, what fears they may have,” he said.

These concerted efforts and the representation of providers across the gender spectrum can improve both patient care now and in the future as the next generation of gastroenterologists look for their niche within medicine.

“With a more diverse professional community, the quality of care will also improve,” Chiang said. “Representation will help attract the most talented next generation of gastroenterologists. Those who feel seen, heard and respected will be less likely to shy away from our field and be able to build communities to address concerns that would otherwise be ignored.”

Day said the data show a more diverse health care team provides better care and produces better outcomes.

“For the time I’ve been a gastroenterologist over the last decade, I’ve definitely seen improvements,” Day said. “We have to be very intentional in making sure we have a diverse workforce to ensure we reflect the community that we’re serving and caring for.”

That starts at the top of every organization and institution, Day said, ensuring diversity within leadership. When he entered GI, Day explained that there was a lack of ‘intentional’ diversity. He had guiding forces in his career, but not many who identified with him as a gay man and American Indian.

“There’s more intentional movement toward embracing and improving diversity at work,” Day said. “Having the discussion, it moves the needle, and it also sends a signal to medical students, trainees, and individuals who are considering a career in health care that diversity is important and that you will feel included in that organization.”

Yet, even as he notes small improvements, there is a lot more work to be done.

“Unfortunately, within the field of GI, in terms of racial/ethnic and gender diversity, it has not significantly changed over the last decade and there is still more work that is needed to improve diversity within our specialty,” Day said.

And he said we need to start with the numbers.

“We don’t have a lot of data on sexual orientation or gender identity with respect to our health care team members. We do a great job in asking and gathering this information for patients ... but we haven’t really done it for our health care providers,” Day said. “Once you have these data, it’s really instrumental. It tells you how well you’re doing or how well you’re not doing.”

Simons pointed out that the cohort entering Harvard Medical School in 2019 self-reported to be 15% LGBTQ, a number she believes to be an understatement.

“I believe we are going to see a wave of LGBTQ+ physicians, PAs and nurses, in the coming years and I am so excited to be part of it,” Simons said.

Just a few years ago, Simons limited her criteria for selecting residencies and fellowships to states that would recognize same-sex parents on a child’s birth certificate. And even with the Supreme Court rulings to make it unconstitutional to not recognize both parents as well as the ruling for same-sex marriage, a physician who is openly part of the LGBTQIA+ community may not feel comfortable in certain areas of the country.

“When I married my partner and when I had my first child, I wanted to celebrate with my colleagues. I feel that if we can share each other’s victories, then we have more compassion for each other’s struggles. I believe this sense of empathy not only allows us to be better health care providers, but better people as well,” Simons said.

Calls to Action

“Diversity, equity and inclusion is essential to health care for our patients. It’s essential to deliver high-quality, safe and equitable care for our patients, and it’s needed. But in addition to that, we need to make sure we act upon it,” Day said.

“I’ve certainly noticed a significant change even in the last few years that I hope continues at this rapid pace,” Schulman said.

Having those conversations at the practice, institution and association levels will allow practitioners to find an appreciation for their colleagues and patients.

“We also have to be intentional in not only creating a safe space for our patients, but also for our staff. Making sure that staff have avenues in terms of mentorship and that staff have a space where we can have conversations regarding diversity and inclusivity in the workplace,” Day said. “We need spaces where staff can speak up if they are seeing something or hearing something and provide their feedback and ideas of where we need to change or intervene upon.”

“It takes all of us to pay close attention to how we communicate with one another, check our own biases, and help each other understand situations that may be perceived as microaggressions or bias,” Chiang said.

The spotlight is on medicine, and gastroenterology can lead the way to improved population health through intentional diversity.

“Diversity and acceptance are like vital signs in medicine in that they are essential to the lives of our colleagues and patients. Now more than ever, we must be a united front on this matter,” Simons said.

“When you look at the bigger picture and again understand what diversity brings to the table, you start to understand that some of the effectiveness and the almost intelligence of our field comes in being diverse, and so there’s a specific merit that comes in having a diverse population,” Iroku said. “In and of itself, having a population that is as diverse as ours is an important thing that actually matters and actually saves lives.”

• References:
• Gomez LE, et al. J Natl Med Assoc. 2019;doi:10.1016/j.jnma.2019.01.006
• Tanner L. U.S. medical schools boost LGBTQ students, doctor training. Available at: https://apnews.com/article/ky-state-wire-health-us-news-ap-top-news-medical-schools-985d50d0a7b1b593acd0dd791e8c3118. Accessed August 11, 2021.
• White PM, et al. Nat Rev Gastroenterol Hepatol. 2021;doi.org/10.1038/s41575-021-00464-y.
• Xu YJ, et al. Endosc Int Open. 2021;doi:10.1055/a-1311-0899.